Transportation Write Up Slip - Galesburg

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Galesburg-Augusta Community Schools
Transportation Disciplinary Referral Form
Student Name: ____________________
Date: _________ Grade: ___ Time: _________
Issued By: ____________________________________________________________________
1. Location
□Bus Loading Zone
□Bus
□Other:___________________________________________________________
2. Class I:
□Yelling/Body Parts out the Window
□Refusal to Admit Responsibility
□Inappropriate Displays of Affection
□Other: ________________________________
□Leaving Seat
□Non-Compliance
□Technology Violation
□Defiance/Disrespect
3. Class II:
□Non-Compliance
□Deceit
□Theft
□Incidental Profanity
□Profanity
□Intimidation
□Extortion
□Bullying Behaviors
□Lying
□Throwing Items Inside/Outside the Bus
□Other: ________________________________
4. Class III:
□Fighting/Physical Aggression
□Physical/Emotional Threat
□Contraband
□Teasing Based On: Religion, Gender, Race, Handicap or Sexual in Nature
□Vandalism
□Extortion
□Other: ________________________________
5. Possible Motivation
□Obtain Peer Attention
□Avoid Tasks/Activities
□Unclear
□Obtain Adult Attention
□Avoid Peers
□Obtain Items/Activities
□Other: _______________________________________________________________
5. Others Involved:
□None □Peers □Staff
□Driver □Substitute
□Unknown
□Other: __________
6. Administrative Decisions (check all that apply):
□Confer w/ student
□Bus Suspension
□In-School Suspension
□Parent contact
□Out-of-School Suspension
□Loss of Privilege
□Individualized Instruction □Other:__________________________________
Comments:
________________________________________________________________
________________________________________________________________
_______________________________________________________
________________________________________________________________
________________________________________________________________
7. Bus Driver Comments:
8. Other Comments:
Administrator Signature: _______________________________ Date: ________________
Parent Signature: _____________________________________ Date: ________________
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